Two Roads Leading Down One Path: Improving Stroke Door-to-CT Times
Denise Brennan, MSN, RN, CNL; Nancy Robin, M.Ed, RN, CEN; Robert Boss, BSN, RN, CEN; Joanne Kane, BSN, RN, CEN; Christopher Amore, ADN, RN; James Corbett, BS, ADN, RN
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Session I presented Saturday, September 16, 2017
Purpose: Stroke Centers work on quality initiatives to improve the care stroke patients receive. In August 2015, door to computerized tomography (CT) scan time was one of the quality metrics which was focused on. Many centers were working on direct to CT for patients that arrived via Emergency Medical Services (EMS) transport, but it was important to have all stroke patients go directly to CT no matter how they arrived. The purpose of this project was to decrease door to CT for both ambulatory and EMS arrivals.
Design: Quality improvement project.
Setting: Teaching, urban emergency department with 67,000 visits.
Participants/Subjects: All ED staff participated.
Methods: Several selected quality improvement initiatives were in process. In January 2014, the CT scanner had been moved to the ED area from radiology. This had helped to decrease times just in transport alone, but there was more work to do. The hospital directed feedback program was designed to help EMS service providers receive timely feedback on their adherence to the prehospital screening protocol. With this well-established partnership, the ED launched a process to have the charge nurse and physician meet EMS at the EMS entrance. The Code Stroke and the stroke order set would be implemented and the patient would go directly to CT. The EMS process was going well, but staff had questioned if it could also be implemented to decrease door to CT on ambulatory patients. Previously, the ambulatory patient was seen by the RN greeter, evaluated by a RN triage nurse and sent back to a room in the main ED. Once in the room, the patient would be evaluated by the nurse and then the physician. These were valuable minutes that were being wasted. In the new process, the greeter calls a Code Stroke and notifies the physician. The physician comes directly to triage to evaluate the patient and perform a Los Angeles Motor Score. The patient now goes directly to CT for CT and/or CT-angiography.
Results/Outcomes: Receiving timely stroke assessment and care should not be dependent on the patient’s mode of arrival. Prior to direct to CT, the median time during August 2014-July 2015 was a little over twenty-seven minutes. Once Direct to CT was in place for both ambulatory and EMS, the time savings was measured from August 2015-July 2016. The median time dropped from 27.5 minutes to 17.9 minutes. With outliers identified, capturing atypical signs and symptoms of mimics is being worked on to enhance stroke identification and door to CT. With door to CT time decreasing, improvements with arrival to tissue plasminogen activator (t-PA) administration were also gained. Other work to improve t-PA administration included a one-minute administration goal after delivered by the pharmacist. A 12% or 13-minute median decrease over the same time period was also actualized.
Implications: Moving to direct to CT for those who arrived by EMS and ambulatory patients should be the standard all ED’s follow. Both arrival paths should lead down the same road of improving processes that perfects door to CT times and overall stroke care.
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